GW1--05879_Well Construction - GW1_20241001

vv ELL LAAAS 1 KUC'FION RECORD GW-1
� ) For Internal Use Only:
1.Well Contractor Information: I
Nick Young
14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
4605-A 1 SO "- AST e2.
NC Well Contractor Certification Number 3 I s 3.f 6 H 3
15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
N.W. Poole Welt and Pump Co. FROM TO DIAMETER THICKNESS MATERIAL
Company Name (e
•
1. l ft- ( 3 fa 67 in.
n •'a, \V,
16.INNER CASING OR TUBING othermal closed-loop) 1
2.Well Construction Permit#: C.2c2t/ -O?p1 FROM To DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIG County,State.Variance,eta) ft. ft in.
3.Well Use(check well use): ft. ft. in
Water Supply Well: 17.SCREEN FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. FL in.
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single)
fL ft ht.
❑lltdustrial/Cotnmercial ❑Residential Water Supply(shared) _
❑Irrigation ❑ 15.GROUT
Wells>100,000 GPD FROM TO MATEF AI EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O rt _a ` rL R.th,�
❑Monitoring ORecov 1
Injection Well: ft.
❑Aquifer Recharge ❑Groundwater Remediation n
❑Aquifer Storage and Recovery ❑Salinity Barrier 19.SAND/GRAVEL PACK(if appli amble)
FROM TO MATERIAL, EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage rt. R
❑Experimenta►Technology ❑Subsidence Control rt. ft. -
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock typq grain iu cm)
4.Date Well(s)Completed: 7 ..2 H Well ITV a It a--? rt
a
5a.Well Location: a�^7 ft. for
IL-5e ' es Cofer a C'lr: _
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f� f�
Facility/Owner Name Facility IN'(if applicable) ft It
-,man la) \ lr4paL Cud, (Li rivri l-llllt+4c In n.
Physical Address,City,and Zip
021.REMARKS
County
V Parcel Identification No.(PIN) Used steel hardened drive shoe
5b.Latitude and longitude in depees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) -
` 22.Certification:
t p.03`j�yt' N 761. O5s ,9L4 W t'
6.Is(are)the wcll(s): it Permanent or 0 Temporary Signal c of ell Contra �^ y
Date
By signing this form,I hereby ce tfit that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ONo ISA NCAC 02C.0100 or 1SA NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature of the oft is record has been provided to the well owner.repair under#21 remarks section or on the back of this form
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info
construction,only I GW 1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled:
G fO�l 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:
For multiple wells list all depths if di,fJerent(example-3( .200'and 2@a 100') (f t) Submit this GW-1 within 30 days of well completion
cap per the following:
10.Static water level below top of casing: Q 0 (n) 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level is above casing use + Information Processing Unit, 1617 MSC,Raleigh,NC 27699-1617
6tr
24b. For Injection Wells: Copy to DWR, Underground Injection Control cue)11.Borehole diameter: (in-)
Rotary Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method:
(i.e.auger,rotary,cable,direct push,etc.) 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY;
24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test: Blow Permit Program, 1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection HTH
type: Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources
Revised 6-6-2018